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L SAN JOAQUIN LOCAL HEALTH. DISTRICT AA <br /> F0 <OFF" E USE: 1601 E. Hazelton Ave. , Stockton, Calif. /0/2174 <br /> •� .. J 3 U Telephone: (209) 466-6781 VI/n � 11 `" <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;?l?_� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedw/_2-7-27 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> PP Y <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ! <br /> County Ordinance No. 1.862 and /the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name /e r� /�/ _ ,: Sj x � _ Phone - .� <br /> a <br /> i <br /> Address City r l' ccc, 9st6 <br /> License 46 Phone 5 <br /> Contractor's Name f/11v4 nl2ll/i�l G C /- - � f? �-/ItT�� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '_tV DEEPEN / / RECONDITION -7 DESTRUCTION <br /> PUMP INSTA CATION. kPUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /UQ SEWER LINES p PIT PRIVY <br /> : SEWAGE DISPOSAL FIELD fZo l CESSPOOL/SEEPAGE PIT OTHER �I <br />" PROPERTY LINE - PRIVATE DOMESTIC WELL/�' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation LA . <br /> Domestic/private Drilled Dia. of Well Casing <br /> -- <br /> Domestic/public. ,� �.....� '.--_Driven n.� .—Gauge .of-Casing--� <br /> Irrigation �_ Gravel Pack Depth of Grout Sear r <br /> Cathodic Protection _� Rotary Type of Grout 1-IDE <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed BV: <br /> AMP INSTALLATION: -,Contractor l - <br /> Type of Pump H. <br /> }µ`UMP REPLACEMENT: . / / State Work-Done <br /> PUMP .REPAIR: / / State Work Done <br /> DE5•TRUCTION OF WELL: Well Diameter .,` ' j -Approximate Depth <br /> Describe Material an ` `rocedure <br /> Material <br /> 4. <br /> I hereby agree to comply with all laws and-regulations of the•.San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my-work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true t6- the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL IN ECTION. ' n <br /> SIGNED + ► - TITLE �S.0 <br /> W. PL T PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> 00, <br /> y. <br /> PHASE I0. <br /> APPLICATION ACCEPTED BY _104 <br /> DATE <br /> ADDITN COMMENTS: . <br /> PHAS I GRO T INSPECTION PHASE II/FIN " INS ECTION �y <br /> INSPE TIO BY DATE INSPECTION BY DATE <br /> 3� TT Na-r{ ; V12,5 <br /> F U l `)ti Dair 1_7G -.� Pa <br />